Riccardo Balestri

Correlation between BMI and PASI in patients affected by moderate to severe psoriasis undergoing biological therapy.

Obesity is common in psoriatic patients, and it has been shown to be important for many aspects of the condition. In particular, low‐calorie diets can improve the symptoms and response to treatment in pustular psoriasis. The present study investigates the influence of body‐weight alteration on the diseases clinical manifestations in moderate to severe psoriasis patients treated with biological drugs. Finally, the influence of a caloric restriction was assessed. This observational transversal study enrolled 33 patients attending our Severe Psoriasis Outpatient Clinic, who were treated with biological drugs. Body Mass Index (BMI) was used as a diagnostic indicator of being overweight and of obesity. Waist circumference was also measured. Body weight and Psoriasis Area Severity Index (PASI) index were measured at follow‐up visits at 4 and 8 months. Nonparametric test of Mann–Whitney was used to detect the differences between patient groups. Fishers exact test was performed to evaluate the different results depending on the therapeutic changes of BMI. There was a strong prevalence of overweight‐obese individuals in the group with a mean BMI of 30.59 ± 6.94. Waist circumference was also above normal in the majority of the patients. Obese patients had a PASI index higher than the average of the whole group (25.03 ± 12.43), with grade III obese patients having an average PASI of 44 ± 3.37. At the first and second follow‐ups, patients who put on weight did not achieve PASI 50; patients who had a stable weight presented variable response to treatment, while patients who decreased their weight achieved PASI 90 or PASI 75 even when not responding at the first. Further studies are needed to understand if the poor response observed in heavier patients is due to biological drugs pharmacokinetics or because therapy should be BMI based rather than administered in fixed doses, posing then an ethical consideration.

Nail digital dermoscopy (onychoscopy) in the diagnosis of onychomycosis.

Background  Distal subungual onychomycosis and traumatic onycholysis are the most common causes of toenail abnormalities, and differential diagnosis is often impossible without mycology.

Partial excision of matrix and phenolic ablation for the treatment of ingrowing toenail: a 36-month follow-up of 197 treated patients.

BACKGROUND Several options for the treatment of ingrowing toenails are available, ranging from simple conservative approaches to extensive surgical procedures. OBJECTIVE To evaluate in a long‐term follow‐up (36 months) the efficacy of chemical matricectomy with phenol for the treatment of ingrowing toenails. METHODS AND MATERIALS A total of 197 phenol ablations were performed in 139 patients with stage 2 and 3 disease. Each patient was examined weekly until full wound healing was achieved and was followed for 36 months to assess the long‐term efficacy of the treatment. The healing period after surgery ranged from 2 to 4 weeks; few postoperative complications were seen. RESULTS Only three recurrences were observed (after 2, 4, and 11 months). Short‐term results were excellent. No severe complications occurred during the 36‐month follow‐up period. Cosmetic results were remarkable. The success rate was 98.5%. CONCLUSIONS Phenol cauterization is an excellent surgical method for the treatment of ingrowing toenails, being simple and associated with low morbidity and a high success rate, even over the long term (36 months). The authors have indicated no significant interest with commercial supporters.

Cutaneous granulomatous reaction to injectable hyaluronic acid gel: Another case

We report a case of a granulomatous reaction in the melolabial folds, occurring 10 days after treatment with Restylane®. The patient, who had previously been treated with the same product in the last 2 years without any adverse effect, developed an unusual early fibrotic reaction that we hypothesized related to hypersensitivity after repeated use. The lesions slowly disappeared with topical steroid therapy. An improved knowledge of the modality of these uncommon adverse effects is necessary to assess the long‐term safety and efficacy of this product.

A novel HPLC-electrochemical detection approach for the determination of D-penicillamine in skin specimens.

D-penicillamine is a thiol drug mainly used for Wilsons disease, rheumatoid arthritis and cystinuria. Adverse effects during normal use of the drug are frequent and may include skin lesions. To evaluate its toxic effects in clinical cases an original method based on high performance liquid chromatography coupled to amperometric detection in a specific biological matrix such as skin has been developed. The chromatographic analysis of D-penicillamine was carried out on a C18 column using a mixture of acid phosphate buffer and methanol as the mobile phase. Satisfactory sensitivity was obtained by oxidizing the molecule at +0.95 V with respect to an Ag/AgCl reference electrode. A chemical reduction of D-penicillamine-protein disulphide bonds using dithioerythritol combined with microwaves was necessary for the determination of the total amount of D-penicillamine in skin specimens. A further solid-phase extraction procedure on C18 cartridges was implemented for the sample clean-up. The whole analytical procedure was validated: high extraction yield (>91.0%) and satisfactory precision (RSD<6.8%) values were obtained. It was successfully applied to skin samples from a patient who was previously under a long-term, high-dose treatment with the drug and presented serious D-penicillamine-related dermatoses. Thus, the method seems to be suitable for the analysis of D-penicillamine in skin tissues.

Analysis of current data on the use of topical rapamycin in the treatment of facial angiofibromas in tuberous sclerosis complex.

Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous syndrome causing hamartomatous growths in multiple organs. Facial angiofibromas occur in up to 80% of patients and can be highly disfiguring. Treatment for these lesions has historically been challenging. Recently, topical rapamycin has been proposed as an effective option to treat angiofibromas but a commercially available compound has not yet been developed.

Mohs surgery for squamous cell carcinoma of the nail: report of 15 cases. Our experience and a long‐term follow‐up

Background  Subungual squamous cell carcinoma (SSCC) is the most common malignancy of the nail unit. Mohs micrographic surgery (MMS) is a microscopically controlled surgical technique that has a high cure rate for skin cancers despite allowing narrow surgical margins.

Overweight, diabetes and disease duration influence clinical severity in Hidradenitis Suppurativa ‐ Acne Inversa. Evidence from the national Italian Registry

DEAR EDITOR, Hidradenitis suppurativa–acne inversa (HS-AI) is a chronic inflammatory skin condition that involves the folliculopilosebaceous units. Histopathological studies have suggested that the occlusion of the follicular infundibulum and both innate and adaptive immunity play central roles. Limited data regarding the clinical aspects and prognosis of HS-AI are available. This paper presents data collected within the newly implemented Italian registry of patients with HS-AI. This was a cross-sectional study on baseline data of a cohort of consecutive patients with a new diagnosis of HS-AI, prospectively observed within a network of Italian dermatology departments. Presence and recurrence, for at least 6 months, of nodules, abscesses, draining sinuses and secondary retracting scars localized on the axillae, suband intermammary areas, inguinal folds, buttocks and perianal areas were considered as inclusion criteria. Written informed consent was obtained from the patients, or from their parents for subjects younger than 18 years, before inclusion in the registry. The study was approved by the ethics committee of the Sant’Anna Hospital in Ferrara. The information collected, using a standardized data collection form, included demographic data, anthropometric measures, selected personal habits, clinical history of the disease, clinical features at entry and follow-up, presence of comorbidities, and therapies prescribed for at least 1 month. The severity of HS-AI was assessed by a physician using the Sartorius score. A short course was run among participants to harmonize Sartorius score calculation, and the inter-rater agreement of independent measures obtained by participants on a small series of patients was judged satisfactory (data not shown). Age-standardized prevalence rates were computed using the 2011 Italian population as a reference. The frequency distribution of selected variables within the HS-AI sample was compared with the distribution in the general population using standardized prevalence ratios along with their 95% confidence intervals (CIs). The Mann–Whitney U-test and Kruskal–Wallis test were used to assess differences across different levels of selected variables for HS severity. To assess which factors were independently associated with HS severity, baseline variables with a P-value < 0 10 in the univariate analysis were evaluated in multivariate linear regression models with forward stepwise selection algorithms. The effects of selected factors were expressed in terms of standardized (Pearson) correlation coefficients (q) along with their 95% CIs and P-values. All tests were considered significant at P < 0 05. From January 2009 to June 2013, 245 patients in seven Italian referral centres for HS-AI were included in the registry; 59 6% of patients were female, and the age at entry was between 6 and 85 years (mean 33 4 13 0), with a mean age at first diagnosis by a physician of 28 2 11 8 years, and a mean Sartorius score of 78 4 66 1 (Table 1). The mean age at onset of the disease was 21 3 10 2 years, and the main affected locations at baseline were the groin/genitals (44 1%), axillae (34 7%), buttocks (10 2%) and trunk (9 0%). The most frequently reported comorbidities were acne (5 7%), thyroid diseases (4 5%) and diabetes (4 1%). Compared with the general Italian population, adult patients (aged ≥ 18 years) with HS-AI were more frequently overweight or obese (age-standardized prevalence ratio 1 4, 95% CI 1 1–1 9), and the prevalence of current smokers was substantially higher (age-standardized prevalence ratio 2 5, 95% CI 1 9–3 4). There were some significant variations between sexes. Age at onset was higher in male patients (24 2 12 7 vs. 19 4 7 6, P = 0 003), while groin/genital involvement was more frequent in female patients (50 7% vs. 34 3%, P = 0 01). In the univariate analysis, age, duration of disease, diagnostic delay, body mass index (BMI), smoking habits and presence of diabetes were all associated with an increased severity of the disease at baseline (Table 2). In the multivariate analysis, duration of disease ≥ 5 years, obesity (BMI ≥ 30 kg m ) and the presence of diabetes were maintained as independent factors directly associated with HS-AI severity. Further analysis showed that smoking correlated with both duration of disease and BMI, with a significant linear trend across different levels of the variables (data not shown). Our data show that the implementation of a registry for HS-AI is feasible and could provide useful data to direct disease management. Smoking and obesity have been proposed as risk factors either to trigger or to exacerbate HS-AI. In our cohort approximately 70% of the patients were current smokers (65 7%) or ex-smokers (8 6%), and the number of current smokers was higher than in the general Italian population. However, we lacked a control group of smokers matched for BMI. Smoking has been associated with increased severity of HS-AI in some studies but not others. In our study smoking

Autoantibodies in psoriatic patients treated with anti-TNF-α therapy.

TNF‐α inhibitors have been associated with induction of autoantibodies and autoimmune diseases. We retrospectively evaluated the incidence of autoantibodies ANA, ENA, anti‐dsDNA, the occurrence of clinical symptoms and possibly related treatment failure.

A 36-week retrospective open trial comparing the efficacy of biological therapies in nail psoriasis

Nail psoriasis occurs in about 50% of psoriatic patients and can be psychologically devastating since it appears on visible areas. Up to now there is no evidence about what biological drugs is the most effective on nail psoriasis.